Simone suggested that I might write a regular column on CBT as I currently work as a CBT psychotherapist in an NHS Early Intervention for Psychosis Service. I’ve been a general and mental health nurse for 30 years, both in New Zealand where I qualified and here in the UK where I’ve lived since 1996. Whilst all the clients in our service have had unusual experiences defined as psychosis (such as hearing voices, seeing visions, paranoia and unusual thinking) much of therapy I deliver is for anxiety, depression, low self-esteem, personality disorder, trauma and abuse.
I thought I would start this first column explaining CBT, thinking about why it is so commonly used and how it works.
What is CBT (Cognitive Behavioural Therapy)?
CBT is a type of talking therapy that is successful in helping people manage a range of difficulties, as noted above. It’s based on the idea that what we think and do affects the way we feel physically and emotionally. We look briefly into the past to understand how this has influenced our lives and how our problems might have started. The focus is predominately on the here and now, thinking about how our experiences affect us now, how we cope and how we can learn new ways of understanding and managing our problems to reduce our current distress.
You may well have heard of CBT as it’s one of the most commonly available forms of talking therapies and is routinely available for free on the NHS, via both primary care/GP and secondary care Community Mental Health Teams (CMHT). There are some increasing downward trends in the amount of sessions available versus what is recommended for particular mental health problems via the NICE (National Institute for Clinical Excellence) guidelines. This means that adults who want therapy should be able to access CBT relatively easily and quickly, but that it is unlikely to be for as many sessions as required.
CBT has a well researched evidence base for its effectiveness and over the decades has been offered for a wide range of emotional distress and mental health disorders. The research indicates that CBT offers at least small gains compared to medication alone or ‘treatment as usual’, and it is currently the recommended first course of treatment by NICE guidelines for both anxiety disorders and depression. It is not considered to have side effects, unlike medications. It is popular with service commissioners because it shows effectiveness over a shorter period of time than other types of psychotherapy and is easier to research than counselling, a term which covers multiple different theories and types of training and is therefore harder to show consistency in researching outcomes.
What does it involve and how does it work?
CBT can be completed in groups and individually. Individual sessions would normally be weekly for 50-60 minutes and the modes of therapy have really expanded in recent years from predominantly face to face to include phone, online and even by text. Since social distancing measures have been introduced these alternative methods are the only forms of therapy being completed just now.
The first one or two sessions are spent thinking together about what problem you are bringing to therapy, what has contributed to this situation and how this cycle is maintained. We think about trigger situations and consider what thoughts go through our mind at the time and how that makes us feel, in terms of our emotions and physical sensations. How then do we behave, what actions do we take to cope? This begins to show us the themes and patterns that occur. Although not necessarily helpful to us, it makes sense that if we think what we think, we will feel and act as we do.
After we have a shared understanding of the problem, we then agree our therapy goals. What is it that would be different if things were better? What would we be doing that we don’t at the moment? What unhelpful coping would we drop if our problem had changed or stopped? We then agree how long our therapy might take, often this will be directed by the service commissioners, although I’m very fortunate to have flexibility within my service. I would usually offer up to 20 sessions, but for childhood trauma this could be over a year. In primary care services this could be as little as six to eight sessions.
The remainder of our sessions form the treatment phase. We agree our interventions, based on the research of what we know works and taking into account your life and experiences. If there’s a number of issues to be addressed we focus on what we consider the most important. In a conscious way we might research and plan to do something differently, noticing the effects this has and adjusting our course accordingly. We can focus on either our behaviour and changing what we do or by considering our cognitions (thoughts), noticing when they are inaccurate and unhelpful and updating these.
CBT progressively builds one session on the next, towards meeting our therapy goals. Given that therapy is only for one hour a week and we are living our everyday life for the remaining 167, it makes sense that we agree homework (or ‘between session actions’ depending on your aversion to school-based connections!). We think together about how we can build on what we have completed in session. The idea of this is not that the therapist ‘sets’ the homework, but that we think about what we might want to discover or try out, to develop our understanding or notice what affect our actions have on ourselves and the situation around us. This tends to start with observing what is happening for us and noticing the cycles in play when we are triggered, researching (maybe fact-finding or noticing how other people experience or react to things) or doing things differently and noticing what happens. This way we can use our new understanding and experience to adapt our old beliefs and behaviour.
I was surprised during my training to find that CBT focuses predominantly on using a behavioural approach in the first instance, as this can give quick and effective results and should enable the client to continue using these methods independently and adapt them to other situations too. I used to think behaviourism was fine for dogs but not for people. However, now I understand it in its updated form, using self-reward and our most important values – not punishment – to motivate and I am converted to its effectiveness! If we don’t see the changes that we want or feel stuck, then it can be helpful to add a cognitive component to improve the effectiveness of therapy. I had thought that CBT was routinely a combination of both, after all it’s called Cognitive Behavioural Therapy!
In my experience, and from the research, changing our behaviour will have the most impact in revising our beliefs or improving our problem, compared to only noticing our thoughts and challenging them. Finding out what happens when we go out despite our fears is more useful than exploring our thoughts about going out and challenging them mentally. Ultimately if we want our problem to change we have to do things differently, that may be to understand and perceive our situation differently but more likely it will be to act differently in some way. Like any therapy, CBT won’t be for everyone but it is a hopeful and successful therapy that in my opinion sits well with other (but not all) modalities, including Powerwood and Simone’s parenting approaches.
In future columns I thought it might be helpful to think about some disorders more specifically, such as anxiety. I also thought something about third wave CBT therapies, such as Compassion Focused Therapy (CFT), Acceptance and Commitment Therapy (ACT) and Mindfulness-Based Cognitive Therapy (MBCT) might be interesting. If there are topics within this range that you would like to see covered, please email firstname.lastname@example.org. I am sure you will understand that I cannot give individual help and I would also like to make it clear I will be approaching topics from an adult therapy perspective as that is where my experience lies.
© Delwyn Kay 2020
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